Sunday, April 27, 2014

I’m writing this aboard a United Airlines flight on route to
Chicago. I haven’t had this much leg room
since I was inside my mother’s womb. I
am now in fear that if the gentleman in front of me reclines his seat, that it
will disfigure me. If this occurs, I
wonder if United would be liable for my pain and suffering. Now
that I think about, throw that seat back, buddy!

Stretch out and relax!

I shouldn’t carp on United as I received an unexpected prize
from the airline. When I passed through
the TSA checkpoint, I was told that I had been awarded a Pre-Check status,
which conferred valuable privileges.
This meant that I did not have to remove my shoes or my jacket. Somehow, the airline had determined that the
Whistleblower posed no flight risk.
Luckily, the airline had not read some of my scathing Whistleblower
posts on their pricing strategy and their deep commitment to customer service.

Do you think that they profiled me to determine that my
shoes likely contained only my feet? For
law enforcement novices, profiling is a technique that everyone knows is
effective, but we are not permitted to utilize. One of the reasons that I feel so safe on El
Al is because they use profiling, among other techniques, to identify
individuals who warrant enhanced scrutiny.

Civil liberty champions, who argue vociferously for civil
rights in classrooms, textbooks and on the airwaves, should consider that I
have a right not to be blown up. This is
not a law school seminar. We’re contemplating
mass murder.

The dark and evil forces that are plotting against us and
others are not constrained by societal laws and norms. President Obama has rightly recognized this
and has not only continued President Bush’s security policies, but has
intensified them. I suspect that there
are many stealth security operations and practices that are operating without
adequate oversight, or even without knowledge of the White House. Familiar with the phrase plausible
deniability?

The high stakes of our world warrant a recalibration of the
balance between security and civil liberties, as has properly occurred. My motto is, read my e-mails and save an
airplane.

Look at what is already public knowledge.

The president authorized the killing of an American citizen
in a foreign country. Good idea?

An accused terrorist was essentially kidnapped from Libya, a
sovereign nation, and transported to the United States to stand trial. What would our response be if another
country infiltrated the U.S. and grabbed a person of interest? Would we shrug it off? I doubt it.

We still have a pile of prisoners in GITMO whom we won’t try
in court, but we won’t release. While I
understand why President Obama back flipped on his promise to close the place
down, the continued existence of the place doesn’t seem to conform to our
values, even if it is legal.

It’s against the law to torture, but the descriptions I’ve
read about our enhanced interrogation techniques sound like torture to me. And, I’m sure we’re doing stuff that I
haven’t read about.

Lots of warrantless intrusions going on, despite what we
hear about the robust FISA court.

Yeah, I know this is a medical commentary blog, and arguably
I’m off message on this post. I’ve
awarded myself a Whistleblower Pre-Check, entitling me to certain privileges.

So, do you think the balance leans too far now in favor of
security? Perhaps, you feel it should
tilt even further in this direction? Name
a policy that you would strengthen or weaken and the risks of this recommendation.

Sunday, April 20, 2014

Wellness
is the new health mantra that has much more to do with marketing than with evidence-based
medicine. Wellness institutions and
practitioners are omnipresent promising benefits that are often untested or
rejected scientifically. Hospitals that
years ago would have shunned new age healing arts, now offer yoga, meditation,
Reiki and massotherapy. Do they do so
because they have had a Damascus Road experience and now believe that these
techniques are effective? Guess again.

Ahead of His Wellness Time?

100 Years Ago Metchnikoff Suggests Probiotics

Wellness
is no longer restricted to medical campuses, costly weekend retreats for
emotional and physical catharses and ubiquitous yoga storefronts. Wellness is now championed by corporate
America. Business leaders argue that
keeping employees well is not only a demonstration of good corporate
citizenship, but is also good business.
Healthy employees, they claim, will reduce health care costs. I agree, but not for the reasons they offer.

Their
premise that wellness program participants will use fewer medical resources sounds
rational, but it may not be true, despite claims from human resource
professionals who want to justify these programs. Here’s the argument. “If we lower employees’ blood pressure, bring
their weight down and control their diabetes better, than these folks will
avoid heart attacks, strokes and surgeries which will save mega bucks and improve
productivity.”

Sure
it sounds right, but is it really true?
Shouldn’t corporations that know the cost of every paper clip be able to
prove that this strategy is sound? Just
earlier this year, a major study on obesity published in the prestigious
Journal of the American Medical Association concluded that overweight individuals
live longer. My point? Just because something sounds like it should
be true, doesn’t make it so.

Many
companies are now coercing employees with financial rewards and penalties
depending upon their success and enthusiasm in participating in company
wellness programs. If you don’t make their
health grade, then the employee will lose serious cash, which may be far in
excess of actual medical costs incurred.
In other words, an unstated motivating factor here may be simply to get
employees pay more health care costs.

Indeed,
two studies published earlier this year in Health Affairs, a peer-reviewed
journal, strongly suggested that corporate wellness programs save company money
simply by cost-shifting to employees. Is
this what is meant by corporate ‘wellness’?

The Cleveland Plain Dealer (PD) reported on April 20th that CVS Caremark is requiring
employees to participate in its wellness program by May 1st or they
will have to fork over $600 more for health care next year. Do we really know that non-participants would
drain the company’s coffers? Realize
that many employees change jobs every few years, and that adverse health
effects of being obese or having elevated blood pressure may take decades to develop. A CVS worker
with a pair of love handles or modest hypertension, isn’t likely to consume
more medical resources in the short term.
Yet, he would be docked on day 1 next year. Does this policy pass the fair and reasonable
test?

The PD
article quotes CVS as claiming that their policy is “the most effective way to
encourage our colleagues to take control of their own health…” This statement breaks the needle on the
hypocrisy meter. The gall that CVS wants
to serve as a health guardian, or should I say health police, while it sells
cigarettes, alcohol, junk food and the sugary beverages that New York City
Mayor Michael Bloomberg has outlawed for health reasons. This is chutzpah of the first order.

If CVS
wants to adopt a sincere health mission, then let them get rid of their Camels,
Marlboros and Lucky Strikes. Otherwise,
their flimsy argument goes right up in smoke.

If a
company truly believes that wellness is right for workers and business, then
create a corporate culture that encourages this and provide leadership. If it’s really as good an idea as they say,
then folks over time will be persuaded to do join in. Leave the financial rewards and penalties
off the field.

I’m
not a wellness antagonist. I support
any activity that is safe and makes people feel better. But making folks pay-to-play in the wellness
game, doesn’t make me feel good.
Perhaps, I need to meditate more on this.

Sunday, April 13, 2014

Folks who have wandered through the Legal Quality category
of this blog understand my views on our perverted and unfair medical
malpractice system. I've been in the arena many times, and always walked away unharmed. If this system were
presented in front of a fair minded and impartial jury, it would be dismantled. Sure, there are positive elements present,
but they are dwarfed and suffocated by the drawbacks. The self-serving
arguments supporting the current system are far outweighed by the financial and
emotional costs that innocent physicians unfairly bear. Tort reform should not be controversial.

You may wish to peruse a few of my medical malpractice posts
before spewing forth vitriol in the comments section.

Beyond the medical arena, who wants to defend the crushing volume
of litigation in the United States? Let
me be bold. I think we have too much litigation
and fear of litigation in this country.
Put that item up for a vote anywhere in the country except at an
American Bar Association convention, and you don’t need to be a soothsayer to
predict the outcome. You just need to be
breathing.

About two years ago, I was sued months after the death of a
patient for whom I provided appropriate care.
Being sued is not a lonely process.
I was among many defendants, including several doctors, a hospital and
other corporate entities.

I reviewed the medical record and reached two conclusions:

(1)My care was appropriate and proper

(2)The record documented the above.

In the medical malpractice arena, it is much more important
what has been documented than what has been done. Meditate on this statement for a few moments.

The complaint against me didn’t offer a single specific
allegation of a breach of my care. Instead,
there was a general statement, which used against every defendant, that we were
negligent. My attorney also could not
divine from the complaint an actual allegation against me. Isn’t
there an obligation to state to the accused what the alleged negligence is?

In Ohio, a physician not involved with the case must sign an
affidavit of merit swearing that there is a reasonable basis that malpractice
occurred before a case can go forward.
While this sounds like a filter, it functions as a sieve. Shockingly, this single physician swore that
every physician deserved to be sued. I
suspect that if a hamster were sued, that this doctor would have put the little
varmint in the dock also.

Many of these physician ‘experts’ earn a substantial portion
of their incomes by serving trial attorneys.
Anyone spot a conflict of interest here?

The case was dropped against everyone, presumably as the
plaintiff’s attorney couldn’t find real experts to support the claims of
negligence.

I thought I was in the clear until the case was refiled a
few months ago. My attorney petitioned
the court to dismiss me as the physician who signed the affidavit of merit was
not in my specialty. The court
agreed. For all I know, this doctor may
have been a psychiatrist.

What a system.
Consider that I’m only one defendant who was drawn into the legal
labyrinth. My malpractice carrier informed me it cost $11,750.22 to defend me, and my case never even reached the discovery
phase. How's that for money well spent?

I wonder what the financial costs are from all of the
unnecessary litigation that our country endures in a year. Probably, enough to truly reform the health
care system. Hey, this gives me an idea…

Sunday, April 6, 2014

To those brave souls who have returned after digesting last
week’s cheerleading on hospitalists, here is the Achilles’s heel of the
system. While the advantages are clear and
substantial, there are serious vulnerabilities which have not yet been adequately
remedied.

Achilles Held by the Heel Being Dipped into the River Styx

Hospitalists cannot appreciate the medical nuances,
personality, family dynamics, life events and prior experiences that may be
well known by the out-patient physician.

There are serious communication lapses, all of which cannot
be bridged. The out-patient doc may know
that the patient’s chest pain is his typical anxiety and that it is not necessary
to repeat the cardiac evaluation that was done 2 years ago. The hospitalist may take a different tack
here.

Despite their best efforts, hospitalists know that they will
not be seeing the patients after discharge.
As they are not permanently vested,
they may not address certain patient concerns, punting these to the outpatient arena. While this may be medically acceptable, it
may be frustrating for some patients.

The hand off back to the out-patient doc after hospital
discharge can be a minefield. Patients
may be on new medications. They may have
had a variety of laboratory and radiology tests. Some of these results might be ‘pending’ at
the time of discharge. How does the
out-patient physician reliably receive these results and understand their
context? Did medical specialists on the
case leave recommendations that the primary physician now has to track and
implement? When the primary care doctor
resumes care of a patient who had a complex hospitalization, is he now
responsible to search out and address every loose end contained within the
voluminous hospital record? Could a single laboratory abnormality buried
in the record that was totally unrelated to the medical illness become a
medico-legal issue years later? Do we
really think that the hospitalists discharge summary to the primary care
physician is airtight?

A primary care physician recently complained to me that the
local hospitalists never call him when his patient is admitted when he might
provide useful information about his patient that only he know. This is a legitimate gripe.

No system is perfect
.

So, over the past 2 weeks you have been offered a fair and
balanced presentation on hospital medicine.
Which side of the issue has the better argument?

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About Me

I am a full time practicing physician and writer. I write about the joys and challenges of medical practice including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When I'm not writing, I'm performing colonoscopies.